Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
.pdf
C H A P T E R 78 • Laparoscopic Inguinal Hernia Repair |
849 |
Dissection through deep fat to Cooper's ligament
Medial umbilical fold
Vas deferens
Inferior epigastric
Cooper's ligament vessels
Rectus abdominis muscle
A
Pubis
Peritoneum
Vas deferens
B
Iliac vessels
Sac dissected from cord
C
FIGURE 78–4
8 5 0 S E C T I O N X I • H E R N I A S
A sheet of polypropylene or polyester mesh is trimmed to shape, tightly rolled, inserted through the scope port, and spread out on the deperitonealized surface.
The mesh should be anchored at the pubic bone, for a short distance along Cooper’s ligament, and along the anterior abdominal wall, taking care to avoid the important neurovascular structures (Figure 78-5).
Edge of graft stapled to transversalis fascia
Edge of peritoneum dissected bluntly for imbrication
A
Staples in graft |
Dangerous areas |
and Cooper's ligament |
for stapling |
B
FIGURE 78–5
C H A P T E R 78 • Laparoscopic Inguinal Hernia Repair |
851 |
The peritoneal flap is used to cover the mesh. The incision in the peritoneum is closed with clips or tacks (Figure 78-6).
FIGURE 78–6
8 5 2 S E C T I O N X I • H E R N I A S
Totally extraperitoneal (TEP) repair
The 10-mm port is first placed using an open approach. A small incision is made along the inferior edge of the umbilicus. The anterior rectus sheath is exposed and incised on either side of the midline. The rectus muscle is retracted laterally from the midline to expose the posterior rectus sheath.
The preperitoneal plane (between the rectus muscle and posterior rectus sheath) is bluntly dissected manually or, preferably, with a balloon dissector. This plane is developed down to the pubic bone (Figure 78-7).
Endoscope with balloon
in preperitoneal space
Bladder
Peritoneum
Pubis
A
Endoscope with balloon advanced inferiorly in preperitoneal space
Peritoneum
Bladder
Pubis
B
FIGURE 78–7
8 5 4 S E C T I O N X I • H E R N I A S
The fatty contents of a direct hernia defect should be reduced and usually excised
(Figure 78-10).
An indirect sac, if not reduced by the balloon inflation, is gently grasped and pulled out of the internal ring and carefully dissected it from the cord structures (Figure 78-11).
The margins of dissection are the midline medially, the anterior superior iliac spine laterally, the transverse arch superiorly, and Cooper’s ligament inferiorly. The polypropylene or polyester mesh is trimmed to shape, rolled tightly, inserted through the 10-mm port, and laid in place to cover the femoral and both inguinal potential orifices. A notch cut for the iliac vessels allows the mesh to lay with less buckling (Figure 78-12).
The mesh can be anchored, if desired, to the pubis, Cooper’s ligament, and the abdominal wall above the transverse arch avoiding the sites of neurovascular structures (see Figure 78-5).
The insufflation is released (while the mesh is held in place if no anchoring is used), and the ports are removed.
Line of incision
Direct hernia
Preperitoneal fat
FIGURE 78–10
8 5 6 S E C T I O N X I • H E R N I A S
3. CLOSURE
The anterior fascia is closed with absorbable suture. The skin incisions are closed with absorbable suture with a subcuticular technique.
The incisions are dressed with tissue adhesive or tapes.
STEP 4: POSTOPERATIVE CARE
These operations are usually performed in the outpatient setting.
An oral narcotic such as hydrocodone is appropriate for pain management.
Patients may return to regular activity as the surgical discomfort resolves.
STEP 5: PEARLS AND PITFALLS
One must avoid fixation clips and tacks in the lower outer quadrant of the mesh. This is where the nerves and large vessels travel.
If the peritoneal membrane is entered during a TEP, inflation of the preperitoneal space can be maintained by placing a Veress needle into the peritoneal cavity in the upper abdomen. Alternatively, the TEP procedure can be converted to a TAPP procedure.
The inferior edge of the mesh should be tucked under the peritoneum as the pneumoperitoneum is released to avoid migration of the mesh.
SELECTED REFERENCES
1. McKernan JB, Laws HL: Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993;7:26-28.
2. Stoppa RE, Warlaumont CR: The preperitoneal approach and prosthetic repair of groin hernia. In Nyhus LM, Condon RE (eds): Hernia, 3rd ed. Philadelphia, Lippincott, 1989, pp 199-225.
3. Liem MS, van Vroonhoven TJ: Laparoscopic inguinal hernia repair. Br J Surg 1996;83:1197-1204.
8 5 8 S E C T I O N X I • H E R N I A S
The hernia is protruding through the femoral canal, which remains only a potential space in most people. The space is bounded anteriorly by the inguinal ligament, posteriorly by the pubic ramus and pectineal ligament, laterally by the femoral vein and sheath, and medially by the lacunar portion of the inguinal ligament.
STEP 2: PREOPERATIVE CONSIDERATIONS
The course of the inguinal ligament parallels a line drawn between the pubic tubercle and the anterior superior iliac spine. Any mass that lies beneath this line and medial to the femoral artery pulsation is a possible femoral hernia.
As outlined later, some preoperative consideration regarding placement of the incision should take place.